Nurse Education in Practice (2005) 5, 78–83

NurseEducation

www.elsevierhealth.com/journals/nepr

in Practice

Preparing student midwives to care forbereaved parents

Mary Mitchell*

Faculty of Health and Social Care, School of Maternal and Child Health, University of the West ofEngland, Blackberry Hill, Stapleton BS16 1DD, UK

Accepted 25 March 2004

Summary Caring for bereaved parents after the death of a baby is emotionallychallenging for midwives. There is a lack of discussion and debate in the literature ofhow student midwives are prepared to undertake this role. This article describes theway student midwives undertaking 3 year and 18 month courses, in one university inthe UK, are prepared to care for bereaved parents and their evaluation of thispreparation. Verbal feedback and student’s comments in the form of reflectivewriting formed the basis of the evaluation. Evaluation of the preparation included afocus on the use of the support group the Stillbirth and Neonatal Death Society, asthis aspect has received little attention in the literature. In the analysis of thestudent feedback five main themes emerged. These were dealing with death andbereaved families, anxieties and fears, teaching strategies, user representation andpreparedness for practice. Teaching about death is challenging and there is a needto share how educators undertake this task and to learn from each other. It is hopedthat this discussion will stimulate a debate surrounding this issue.

�c 2004 Elsevier Ltd. All rights reserved.

KEYWORDSDeath education;Grief and bereavement;Midwifery education

Introduction

Every midwife will be involved in providing care forbereaved parents at some time in their career.Supporting these parents is a crucial aspect of amidwives practice and preparation to fulfil this roleis required. Midwives often experience difficultieswith this aspect of practice, yet the care providedaround the time of a baby’s death could have asignificant impact on the parent’s ability to cope.Surprisingly, there is no discussion in the literatureon the preparation student midwives receive, or

* Tel.: +44-117-3448892; fax: +44-117-3448411.E-mail address: mary.mitchell@uwe.ac.uk

1471-5953/$ - see front matter �c 2004 Elsevier Ltd. All rights reserdoi:10.1016/j.nepr.2004.03.005

the problems encountered. This article presentsthe evaluation of a preparatory session, which aimsto prepare student midwives for supporting be-reaved parents. Included is the research evidenceto support the rationale and teaching strategiesutilised, including the role of the support group theStillbirth and Neonatal Death Society (SANDS).

Perhaps the lack of discussion in the literaturereflects the view that death is a morbid subject.Many writers agree that the western culture is adeath denying society (Gates et al., 1992; Mander,1994). The majority of individuals are relativelyisolated from death and hence midwifery studentsand other health professionals may have little or noexperience of death. This is particularly true for

ved.

Preparing student midwives to care 79

death around the time of birth. Developments inhealthcare and the introduction of antenatalscreening have fostered the belief that if a problemdevelops medical intervention can solve it and apregnancy lost is seen as failure both from the par-ents and medical viewpoints (Rothman, 1988). Thesilence of death around the time of birth has beenbroken in recent years. This is thanks to individualwomen who have spoken out and organisations suchas SANDS. This supports Murray-Parkes (2002) whosuggests that in the UK it has been the voluntaryservices for the bereaved that have flourishedwhereas in the USA a different direction has ensuredthat death education has become a major part oftraining for health professionals. Downe-Wamboltand Tamlyn (1997) agree that there is a paucity ofinformation about death education in the UK. De-spite a thorough literature search of medical, mid-wifery and education databases no literature on thepreparation of student midwives could be found.Literature related to teaching other health profes-sionals has been accessed and utilised for this paper.

There is a consensus in the literature that theexperience of the death of a baby can cause pro-found grief with significant short and long termpsychological and emotional effects for both par-ents (Slade and Cecil, 1994; Radestad, 2001). Thedifficulties that parents’ face when a baby dies andthe interventions that are viewed as helpful are nowwell documented (Mander, 1994; Moulder, 1998;Kohner and Henley, 2001; Stillbirth and NeonatalDeath Society, 1995). However, practices sur-rounding the care of bereaved parents have changedover the years. Health professionals may not alwaysknowwhat is best for this client group (Hughes et al.,2002). Indeed McHaffie et al. (2001) found that be-reavement care does not always meet with parentalexpectations. In addition, students may not alwaysexperiencewhat is considered “best practice” in theclinical arena. Radestad (2001) found that 40% ofwomen who had lost a baby had negative experi-ences of care, related to what some members ofstaff had said or done. Yet bereaved parents turn tohealth professionals for advice and support follow-ing the death of a baby (Lovell, 2001). Caring forbereaved parents is challenging and emotionallydraining. Midwives report the most demanding as-pects of this role is in providing emotional support toparents, acting as the woman’s advocate and facingthe reality of pain anddeath in themselves (Moulder,1998). Those interested in improving care to be-reaved individuals argue that professionals mustface their own fears and come to an understandingof the meaning of death. If this does not happen,professionals may be inclined to provide physicalcare but create an emotional and social distance

between themselves and the bereaved (Hurtig andStewin, 1990; Johansson and Lally, 1991).

There is a need for educational programmes tohelp practitioners focus on psychosocial elements inthe care of the bereaved. A lack of knowledge andskills can make professionals feel inadequate andhelpless. In addition a lack of self-awareness maylead professionals to be overprotective or oversentimental in their approach (Penson, 1990). Edu-cation about death is a complex and sensitive issue.Fuller (1999) discusses the challenges of teachingbereavement to medical staff with little experienceof death. Corr (2002) admits that despite 22 yearsexperience of death education he still finds it per-sonally challenging. Whittle (2002) found thatteachers involved in death education experiencedoubts of whether they “are doing it right”. Thefollowing is an account of how student midwives, ina university setting, are prepared to care for be-reaved parents and their evaluation of that prepa-ration. Whilst this is not innovatory practice there isa need to evaluate such preparation to assess whe-ther goals are achieved (Nelson et al., 2000).

Teaching about loss and bereavement

Student midwives are exposed to issues surround-ing grief and bereavement at various pointsthroughout the curriculum in sessions such as earlypregnancy loss, therapeutic abortion and congeni-tal abnormalities. In a module that deals with highrisk pregnancy one day is devoted to this topic.Students are given the opportunity to raise con-cerns about the forthcoming day and are offered anindividual meeting with the midwife teacher if theyhave any related issues. A range of support systemsare in place, including counselling should the stu-dent require help. The day is always led by twomidwifery teachers, one being available to supportstudents if they feel unable to continue with thesession. Appropriate action plans to deal with stu-dent distress are discussed and in place prior to thesession. The day begins with an exploration offeelings surrounding loss, these are then applied tothe loss of a baby. The work of Kubler-Ross (1970)and Worden (1991) provides a theoretical back-ground of grief reactions. It is recognised thatcriticisms of these works exist and that the phasesand task of grief as described in these works havebeen misused (Murray-Parkes, 2002). However, it isemphasised that these are theoretical frameworksand individuals may react very differently. Thediversity of parental reactions and the gender dif-ferences between men and women are discussed.Indeed, Downe-Wambolt and Tamlyn (1997) say

80 M. Mitchell

this is an essential component of any programmedealing with bereavement. The students watch avideo that details one particular family’s experi-ence of the death of a baby and the care that theyreceived from midwives. Appropriate evidence-based interventions for helping bereaved parentscope are included, with particular attention paid tothe guidelines compiled by Stillbirth and NeonatalDeath Society (1995). Plenty of time is allocatedfor students to ask questions and discuss issues thatcause anxiety in providing care for bereaved par-ents. The role of the midwife teacher here is dif-ficult, balancing the opportunity for individuals toshare personal experiences with the needs of thegroup as a whole. Flexibility is essential and feed-back from group work must be tactfully managed inorder to facilitate learning (Corr, 2002). A range ofsupport strategies to help students and midwives tocope, such as counselling and debriefing are alsodiscussed.

In the afternoon the leader of the local SANDSgroup with one or two representatives recountpersonal experiences and discuss the role of SANDSin providing support to bereaved parents. All thecontributing representatives are of Caucasian ori-gin. This is important to acknowledge in evaluatingtheir input, as different ethnic and cultural groupsmay ascribe different meaning to the loss of a baby(Hall, 2001). There is a danger that individualspresenting information from a personal viewpointnegates the diversity of human experience sur-rounding the death of a baby. There was also theworry that individuals in recounting their personalexperiences would become over emotional andtherefore be unable to contribute to the studentslearning experience. This was the rationale forsuch in-depth evaluation and as such does not meetthe criteria for evaluative research. There is littlediscussion in the literature on the role of supportgroups in education about bereavement. In a sur-vey of nursing and medical schools Downe-Wamboltand Tamlyn (1997) found that although the ma-jority of faculties incorporated death education inthe curriculum, none cited involving supportgroups.

Evaluation

Students provided verbal feedback and writtencomments in the form of reflective writing detail-ing their thoughts and feelings surrounding theirlearning experience from that preparation session.Structured evaluation forms were not utilised andno particular model of reflection was recom-mended. Students provided rich detailed reflec-

tions, which indicated that they had given muchthought to the events of the day. The amount ofwriting varied but many students provided between1 and 2 sheets of A4. Verbal comments were re-corded by the facilitator at the completion of thepreparatory session. Forty-five written reflectionswere submitted, out of a total of 58 students.Eighteen month students and 3 year students wereproportionally represented. All students were fe-male and of Caucasian origin As this was the eval-uation of a teaching session, ethical approval wasnot required. Consent for the evaluation to con-tribute to this article was obtained and guaranteesof confidentiality and anonymity were given.

The reflections were analysed for emergingthemes in a series of stages. First the reflectionswere read through and all the text was organisedinto key words and phrases. These were thengrouped under five main categories which are usedto discuss and present the findings. In addition acolleague read through the reflections and agreedthat the five categories were accurate descriptionsof the student accounts. This process is similar tothat described in the analysis of qualitative re-search and contributes to the auditability andtrustworthiness of the findings (Abbot and Saps-ford, 1998). In analysing the reflections it becameapparent that there were little differences in thethemes to emerge for the 18 month group and the 3year group therefore the evaluation is presented asa whole. This was surprising as it was felt that thepast experience of dealing with death as a nursewould ensure that this group felt more prepared tofulfil this role as a midwife.

Dealing with death and bereaved families

Students experienced a dichotomy of feelings sur-rounding the day. Most students found the day veryemotive and challenging. They described theirfeelings in diverse ways, illustrating the complexi-ties in teaching and learning about death.

“The day was intense, interesting and challenging. I feltexhausted at the end of the day. A day charged with manypowerful emotions”.

This is not an unexpected finding as Gates et al.(1992) also found that nursing and medical studentsexhibited an aversion to talking about death anddying and providing care. Conversely the samestudents displayed positive attitudes in terms ofgaining professional competence and satisfactionfrom involvement with death and bereaved fami-lies. One student commented on the positive as-pects of providing care to bereaved parents

Preparing student midwives to care 81

“I derive a great deal of satisfaction in being able to offerhelp and advice and the making of positive memorieswhich I know that women, partners and family will carrywith them for the rest of their days and therefore it is aprivilege to be a part of that”.

Students anxieties and fears

Many students wrote about their fears and anxi-eties in discussing issues of death and in caring forbereaved families. Some students reported thattheir previous experiences of dealing with thedeath of a baby within their midwifery training hadgiven them confidence and they felt comfortablediscussing these issues. Other students felt thatone of their biggest worries was being involvedwith the death of a baby. There were various as-pects that caused students concern. In particular,not knowing what to do or say to bereaved parentsand worries about their own ability to cope withthe situation

“One of my biggest worries was the fear of being arounddeath, especially a baby”

and another student wrote

“I was worried about my ability to cope with the loss of ababy”.

Other students reported having had many unan-swered questions before the session and yet otherstudents were concerned about feelings thatemerged in themselves as a result of past experi-ences. The experience of resurrecting feelings instudents and midwives is also reported by Moulder(1998) and was therefore expected. This highlightsthe need for anticipatory preparation for such asevent.

It is acknowledged that an individuals’ personalknowledge of death may enhance or detract fromtheir ability to provide care to others depending onhow they have dealt with that experience (Hunter,2001; Johnson, 1994). It is therefore importantthat educational programmes encourage studentsto learn from personal feelings. Students need toknow that they are not alone in experiencing theseemotions. Many writers stress how emotionallydraining it is in caring for bereaved parents (Kohnerand Henley, 2001; Warland, 2000). Indeed, War-land (2000) argues that health providers must beself-aware. If an individuals’ coping strategy is thatthey shield themselves from emotional pain by re-maining professionally detached this could causesignificant distress to the parents.

Students also made many comments that theirworries and fears had been relieved to a certainextent.

“I will not be as worried about showing emotions and say-ing/not saying things. I feel more confident to deal withthis problem. Before this day I was afraid I would be tooupset to deal with the delivery of a stillbirth but now Ihave learned it is OK to shed a tear and show feelings”.

Since it is likely that students have such diverseexperiences it also likely that death educationhas diverse effects on individuals and their anxi-ety levels. Indeed, some studies show an increasein death anxiety and yet others no differencefollowing educational programmes (Knight andElfenbein, 1993; Johansson and Lally, 1991;Hainsworth, 1996). However, the validity of usingthe criterion of anxiety to measure effectivenessof programmes is questionable when we areconcerned about the impact that the professionalhas on the care that bereaved families receive. Inaddition Papadatou (1997) suggests that merelyexposing individuals to death related topics pro-vokes discomfort and that such a process may benecessary if professionals are to deal with theirown unresolved feelings surrounding death. Thismay be another reason for the apparent similar-ities between the 18 month and 3 year students.Indeed, the impact of death education may notbe immediate. Students may not realise the im-pact of their learning until faced with the situa-tion of providing bereavement care in clinicalpractice.

Teaching strategies

Many comments were received regarding the var-ious strategies that were utilised throughout theday. The majority of comments surrounded thestudent centred approache. Interestingly none ofthe students commented on the theory input.Perhaps this reflected the value students place onlearning through discussion rather than didacticmethods. Our students experiences seem to con-cur with the consensus from research studies thatstudent centredprogrammes are more effective inpreparing practitioners for dealing with death(Knight and Elfenbein, 1993; Attig, 1992; Heuser,1995). Indeed, Penson (1990) suggests that formallectures are rarely appropriate and suggests avariety of approaches to deal with the differentlevels of knowledge, skills and attitudes that arerequired in caring for the bereaved. Attig (1992)suggests that programmes which concentrate oninformation giving, fail to support the student inreflecting on the meaning of that information.

The discussion sessions were appreciated withmany students commenting on the value of sharingexperiences

82 M. Mitchell

“The discussion helped everyone open up and feel free todiscuss any issues related to loss and grief that we had ex-perienced or had been involved with. I think this particu-larly eased my worries that potentially could haveharboured and not dealt with effectively”.

Attig (1992) suggests that discussion groups arevalid from two viewpoints. Firstly, they help thosewho do not have significant past experiences togain insight into a variety of experiences profes-sionals are likely to encounter. Secondly, studentsgain experiences in speaking for themselves,clarifying their reactions and exploring theirthoughts and behaviours in response to dealingwith death.

Many students commented that the day washandled sensitively and with kindness, whichmade the day easier. Teachers on this day mayfeel some reassurance from this. It is known thatteachers of death education often feel unsure oftheir skills in delivering programmes such as this(Whittle (2002).

User representation

The most positive comments received related tothe input of the speakers from SANDS. This relievedsome of our concerns regarding this approach.They provide support for the continuation of thispractice and the inclusion of user groups in thepreparation of student midwives to care for be-reaved parents. The students felt privileged tohear the parents’ painful experiences of the deathof a baby and admired the courage and honesty ofthe women. Many students wrote rich and mean-ingful accounts. The following comments illustratethe insight gained from listening to these women’sstories and how much they valued the input.

“The SANDS speakers allowed us a unique insight into thefeelings and emotions of women who have had a still-birth. There is little or no chance that a situation wouldarise in practice, which would allow us to gain an insightin such a way. I can think of no other way in which profes-sionals can be educated specifically to a couples needs atsuch a time and in such a personal way”.

The input helped the students gain empathy, animportant skill for professionals in dealing withbereaved parents (Kohner and Henley, 2001)

“I don’t think anyone can be more aware of what a couplego through when a tragedy like this happens but when youlisten tootherpeoplesexperiencesyoucan try to imagine”.

The students also recognised the limitations ofprofessionals in knowing what is best for their pa-tients. This has been acknowledged by McHaffieet al. (2001) in her evaluation of services offered tobereaved parents.

“the other positive part of the session was that as healthprofessionals we often know best, we need speakers fromorganisations such as this to remind us that often wedon’t and it is their needs and wants that are importantto us in our work. The openness of the speakers encour-aged discussion and questioning. They spoke quite freelyof their experiences which gave us permission to ask quiteemotional and probing questions perhaps ones that we re-ally wanted to ask but didn’t feel that you could given thedistressing situation”.

Students gaining an appreciation of the work ofSANDS and the importance of a support network forbereaved parents. There is little in the literature tosupport the value of involving consumer groups indeath education. Attig (1992) discusses the use ofstory telling and first person accounts as a teachingstrategy to counteract the tendency to imperson-ality in death education. He suggests that throughexposing students to a wide array of vivid stories apowerful memory device is triggered that enhanceseffective learning. Students remember the ideaslearned as they recall the stories and the people inthem.

Preparedness for practice

The students had the ability to make applicationfrom events of the day to the practice environment

“Two days after the session I looked after a women whosebaby died. All that I had learned and how I reacted wasmainly because of the information the speakers gave us”

Most importantly the preparation gave them con-fidence in knowing what to say and what not to say,the importance of giving women the opportunity totalk about their experiences and to listen. Theywere aware of the SANDS guidelines for practice.There were able to identify the importance ofcreating positive memories for bereaved parentsand were freely promoting the work of SANDS towomen and colleagues. One student commented onassisting her husband who is a GP deal with a clientwho had a stillbirth. Students also seemed moreaware of the need to recognise differences ingrieving between men and women and felt theycould help women understand better how theirpartners were feeling.

The students gained an understanding of how thecare received by parents will have an impact on howthey come to terms with their loss and a betterappreciation of feelings in subsequent pregnancies.This is a positive outcome as Caellie et al. (2002)argue that the effects of loss on a subsequentpregnancy have received scant attention in the lit-erature. It also contributes to dispel the often heldmyth that a future pregnancy will relieve the grief.

Preparing student midwives to care 83

“I realised what an impact and impression that we as mid-wives can make by our actions and words”.

It is impossible to say whether the meaning thatstudents ascribe to the death of a baby was alteredbut many commented on the possibility of positiveoutcomes.

“they gave me an insight that through a dreadful situationthat good relationships can develop and provide positiveoutcomes for a woman and her partner”

Overall, it is possible to conclude that the studentsgained much learning from this day. However,death education is a life long process and thispreparation is only part of a learning curve, muchof which also takes place in clinical practice andfrom personal experiences. Nevertheless, thepreparation partly fullfils the aims set out by Koh-ner and Henley (2001) that education should enableprofessionals to have a better understanding ofparents’ experiences and needs around the time oftheir babies death and to feel more confidentabout providing a service. What is not known, iswhether this preparation is sufficient to enablestudent midwives to undertake this important roleand whether bereaved parents receive appropriatecare because of it. Further research is needed,particularly in relation to the role of support groupssuch as SANDS in preparing midwives to care forbereaved parents. It is hoped that this article willstimulate discussion on this topic, which is muchneglected in midwifery literature.

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